Remote Clinical Prior Authorization Reviewer

Actalent; Dallas (TX); Remote; USD 48,000 - 55,000; Full time

Job summary

Actalent is seeking a Clinical Prior Authorization Reviewer to join our remote team supporting Dallas, TX operations. This contract role focuses on evaluating prior authorization requests for medical necessity and appropriate level of care using InterQual and Milliman criteria.

You will collaborate with clinical and non-clinical colleagues, document findings in One Note, and stay current with utilization management standards to ensure compliant and timely reviews.

Qualifications

• 24 years of related experience in clinical review or prior authorization.
• Experience with prior authorization processes.
• Hands-on experience using InterQual criteria for clinical review.
• Hands-on experience using Milliman (MCG) guidelines for clinical review.
• Knowledge of utilization management policies, regulations, and standard practices.
• Ability to assess medical necessity and appropriate level of care.
• Strong analytical and critical thinking skills.

Responsibilities

• Review prior authorization requests on a routine basis to determine medical necessity of services and appropriate level of care.
• Evaluate requests in accordance with national clinical standards, contractual requirements, and individual member benefit coverage.
• Assess more complex authorization cases and identify situations that require additional clinical consideration.
• Develop and present clear, well-supported recommendations to the medical team for complex authorization requests.
• Support quality and cost-effective medical care by applying utilization management policies, regulations, and guidelines.
• Use tools such as InterQual and Milliman to conduct clinical reviews and inform authorization decisions.
• Document clinical review findings and recommendations accurately and consistently, including use of systems such as One Note.
• Collaborate with clinical and non-clinical team members to ensure timely and appropriate authorization decisions.
• Stay current with utilization management standards, policies, and regulations to maintain compliance in all reviews.

Skills

Clinical review

Analytical thinking

Utilization management

Team collaboration

Time management

Tools

InterQual

Milliman (MCG)

Job description

Actalent is seeking a Clinical Prior Authorization Reviewer to join our remote team supporting Dallas, TX operations. This contract role focuses on evaluating prior authorization requests for medical necessity and appropriate level of care using InterQual and Milliman criteria.

You will collaborate with clinical and non-clinical colleagues, document findings in One Note, and stay current with utilization management standards to ensure compliant and timely reviews.